Decision-making support among racial and ethnic minorities diagnosed with breast or prostate cancer: A systematic review of the literature

Assessing Algorithmic Fairness With a Multimodal Artificial Intelligence Model in Men of African and Non-African Origin on NRG Oncology Prostate Cancer Phase III Trials

PURPOSE

Artificial intelligence (AI) tools could improve clinical decision making or exacerbate inequities because of bias. African American (AA) men reportedly have a worse prognosis for prostate cancer (PCa) and are underrepresented in the development genomic biomarkers. We assess the generalizability of tools developed using a multimodal AI (MMAI) deep learning system using digital histopathology and clinical data from NRG/Radiation Therapy Oncology Group PCa trials across racial subgroups.

METHODS

In total, 5,708 patients from five randomized phase III trials were included. Two MMAI algorithms were evaluated: (1) the distant metastasis (DM) MMAI model optimized to predict risk of DM, and (2) the PCa-specific mortality (PCSM) MMAI model optimized to focus on prediction death in the presence of DM (DDM). The prognostic performance of the MMAI algorithms was evaluated in AA and non-AA subgroups using time to DM (primary end point) and time to DDM (secondary end point). Exploratory end points included time to biochemical failure and overall survival with Fine-Gray or Cox proportional hazards models. Cumulative incidence estimates were computed for time-to-event end points and compared using Gray's test.

RESULTS

There were 948 (16.6%) AA patients, 4,731 non-AA patients (82.9%), and 29 (0.5%) patients with unknown or missing race status. The DM-MMAI algorithm showed a strong prognostic signal for DM in the AA (subdistribution hazard ratio [sHR], 1.2 [95% CI, 1.0 to 1.3]; P = .007) and non-AA subgroups (sHR, 1.4 [95% CI, 1.3 to 1.5]; P < .001). Similarly, the PCSM-MMAI score showed a strong prognostic signal for DDM in both AA (sHR, 1.3 [95% CI, 1.1 to 1.5]; P = .001) and non-AA subgroups (sHR, 1.5 [95% CI, 1.4 to 1.6]; P < .001), with similar distributions of risk.

CONCLUSION

Using cooperative group data sets with a racially diverse population, the MMAI algorithm performed well across racial subgroups without evidence of algorithmic bias.

Interventions Addressing Health Literacy in Cancer Care: A Systematic Review of Reviews

(1) Background: Interventions addressing the health literacy (HL) of people suffering from an illness such as cancer can improve the understanding of the illness and lead to better-adapted behaviors, regarding the participation in cancer screenings, adhering to the complex multimodal therapy, participating in cancer treatment, and self-managing everyday health. This study provides a review of systematic reviews that include intervention articles addressing the HL of patients, healthcare professionals, and/or organizations in cancer, to identify the factors related to their effectiveness, as well as the missing elements, in light of the recent developments in HL research and practice. (2) Methods: A literature search was performed in Embase, Pubmed, PsycINFO, and Science Direct. Existing published reviews of studies targeting the interventions in the oncology domain, and which explicitly mentioned HL as a factor/outcome, were included. (3) Results: One hundred and fifty-five studies were retrieved. Ten fit the criteria and were included in this review. (4) Conclusions: Most of the interventions addressing HL in people with cancer included the target patients' information and communication skills through education. To keep the full scope of the concept, as investigated in the recent literature, clinical applications of HL in patients with cancer should also consider organizational HL.

Drivers and barriers to health-seeking behaviors and interactions: a qualitative study of Black patients with lung cancer and with peripheral artery disease

OBJECTIVE

To identify factors that may influence health-seeking behaviors and health system interactions from the perspective of Black patients with lung cancer (LC) or peripheral artery disease (PAD).

METHODS

Semi-structured interviews were conducted virtually with Black patients in the United States. Thematic analysis of interview transcripts was performed. The Sense-Think-ACT-Relate (STAR) behavioral framework was used to map emerging themes of drivers and barriers to health-seeking behaviors and health system interactions.

RESULTS

Thirty Black patients with LC (n = 15) and PAD (n = 15) participated in this study. The mean age of participants was 53.4 years, 22 were female, and half lived in an urban area or large city. Factors that shape health-seeking behaviors spanned several framework domains including Trust, Rational and Emotional Associations, Cultural, and Situational. Having a provider who was friendly, knowledgeable, and understood the patient's lived experience was a key driver to seeking care. Barriers to care included patients not recognizing disease symptoms, reservations about seeking care, having previous negative interactions with healthcare systems, and feeling stigmatized or excluded. Situational influences, such as financial cost of accessing and receiving healthcare, also acted as barriers. Similar themes emerged for the LC versus PAD cohorts.

CONCLUSION

Multiple drivers and barriers to health-seeking behaviors exist for Black patients with LC versus PAD, including patients' perceptions of previous health system interactions. Because of known inequities experienced by Black patients, these results highlight the need for interventions that address more than just medical needs but that also encourage patients to seek care when they experience early symptoms and prioritize establishing patient-provider relationships built on trust, respect, and cultural understanding.

Fentanyl in cancer pain management: avoiding hasty judgments and discerning its potential benefits

Cancer pain is an important challenge in treatment and requires a rapid onset of action for its control. In particular, breakthrough cancer pain (BTcP) should be adequately controlled with a stable dose of a short-acting oral opioid. Fentanyl is a synthetic, highly selective opioid with many advantageous chemical properties, including high lipophilicity and distinct pharmacokinetic properties. It is recommended for pain management in a variety of settings, including acute pain, chronic pain and BTcP. To date, its variously designed formulations allow non-invasive administration; amongst others, sublingual fentanyl has proven useful in the management of BTcP and in improving the quality of life of patients with cancer. This review provides an update on the management of BTcP with fentanyl, with consideration of safety, as it remains an important tool in the treatment of cancer pain.

Patient navigation across the cancer care continuum: An overview of systematic reviews and emerging literature

Patient navigation is a strategy for overcoming barriers to reduce disparities and to improve access and outcomes. The aim of this umbrella review was to identify, critically appraise, synthesize, and present the best available evidence to inform policy and planning regarding patient navigation across the cancer continuum. Systematic reviews examining navigation in cancer care were identified in the Cochrane Central Register of Controlled Trials (CENTRAL), PubMed, Embase, Cumulative Index of Nursing and Allied Health (CINAHL), Epistemonikos, and Prospective Register of Systematic Reviews (PROSPERO) databases and in the gray literature from January 1, 2012, to April 19, 2022. Data were screened, extracted, and appraised independently by two authors. The JBI Critical Appraisal Checklist for Systematic Review and Research Syntheses was used for quality appraisal. Emerging literature up to May 25, 2022, was also explored to capture primary research published beyond the coverage of included systematic reviews. Of the 2062 unique records identified, 61 systematic reviews were included. Fifty-four reviews were quantitative or mixed-methods reviews, reporting on the effectiveness of cancer patient navigation, including 12 reviews reporting costs or cost-effectiveness outcomes. Seven qualitative reviews explored navigation needs, barriers, and experiences. In addition, 53 primary studies published since 2021 were included. Patient navigation is effective in improving participation in cancer screening and reducing the time from screening to diagnosis and from diagnosis to treatment initiation. Emerging evidence suggests that patient navigation improves quality of life and patient satisfaction with care in the survivorship phase and reduces hospital readmission in the active treatment and survivorship care phases. Palliative care data were extremely limited. Economic evaluations from the United States suggest the potential cost-effectiveness of navigation in screening programs.

The Neurobiology of Trauma: Developing a Decision Aid for the Care of Persons After Sexual Assault

The care of the person who has been sexually assaulted is challenging because of the neurobiology of trauma, susceptibility to re-victimization, and time constraints. Everyone involved with their care needs to be cognizant of the psychological-physiological phenomena of trauma in order to provide sensitive, high-quality care to these individuals. The neurobiology of trauma explains why the person's memory may be fragmented or impaired. Trauma-informed care offers choices and empowerment to the person along with safety, cultural awareness, trust, and collaboration. Shared decision making empowers the person by educating them on their care choices in collaboration with the health-care provider. This article discusses the development of a decision aid that supports the information used in shared decision making, for use in planning the care for a person who has been sexually assaulted. Based on the understanding of the neurobiology of trauma, the decision aid incorporates a written tool that provides education and information to prepare the person to make care/treatment decisions which are important to them, within a trauma-informed environment.

Attitudes toward COVID-19 Vaccine Uptake: A Qualitative Study of Mostly Immigrant Racial/Ethnic Minority Older Adults

(1) Background: Few qualitative studies address diverse older adults' perceptions of COVID-19 vaccination in the United States, including non-English speakers and immigrant populations. This study aims to understand the attitudes of diverse, primarily immigrant older adults in the U.S. toward the COVID-19 vaccine and its influences on their vaccination decision-making. (2) Methods: The research team conducted semi-structured interviews (N = 100) in 2021 focused on understanding ethnically/racially diverse older adults' perceptions of the COVID-19 vaccine. Interviews were recorded, coded, and analyzed using a thematic analysis approach. (3) Results: Thematic analyses identified three themes. (1) Older adults showed mixed attitudes toward the COVID-19 vaccine associated with information consumed and trust in healthcare systems; (2) health concerns and underlying medical conditions were the most influential factors of vaccine uptake; and (3) systemic barriers and trusted figures impacted vaccination decision-making of older adults. (4) Conclusions: Accessible information in diverse languages tailored to the community's fears is needed to combat vaccine mistrust. Vaccine rollout programs need to tackle the fear of vaccine side effects. Attitudes of religious leaders, family members, and physicians considerably influenced vaccine uptake, suggesting their role as trusted members for vaccine messaging for older, primarily immigrant adults. Systemic barriers, namely lack of transportation and inaccessible vaccination sites, contributed to vaccine deterrence.

Effects of a smartphone application named "Shared Decision Making Assistant" for informed patients with primary liver cancer in decision-making in China: a quasi-experimental study

BACKGROUND

It is well known that decision aids can promote patients' participation in decision-making, increase patients' decision preparation and reduce decision conflict. The goal of this study is to explore the effects of a "Shared Decision Making Assistant" smartphone application on the decision-making of informed patients with Primary Liver Cancer (PLC) in China.

METHODS

In this quasi-experimental study , 180 PLC patients who knew their real diagnoses in the Eastern Hepatobiliary Surgery Hospital, Naval Medical University, Shanghai, China, from April to December 2020 were randomly assigned to a control group and an intervention group. Patients in the intervention group had an access to the "Shared Decision Making Assistant" application in decision-making, which included primary liver cancer treatment knowledge, decision aids path, continuing nursing care video clips, latest information browsing and interactive platforms. The study used decision conflict scores to evaluate the primary outcome, and the data of decision preparation, decision self-efficacy, decision satisfaction and regret, and knowledge of PLC treatment for secondary outcomes. Then, the data were entered into the SPSS 22.0 software and were analyzed by descriptive statistics, Chi-square, independent t-test, paired t-test, and Mann-Whitney tests.

RESULTS

Informed PLC patients in the intervention group ("SDM Assistant" group) had significantly lower decision conflict scores than those in the control group. ("SDM Assistant" group: 16.89 ± 8.80 vs. control group: 26.75 ± 9.79, P < 0.05). Meanwhile, the decision preparation score (80.73 ± 8.16), decision self-efficacy score (87.75 ± 6.87), decision satisfaction score (25.68 ± 2.10) and knowledge of PLC treatment score (14.52 ± 1.91) of the intervention group were significantly higher than those of the control group patients (P < 0.05) at the end of the study. However, the scores of "regret of decision making" between the two groups had no statistical significance after 3 months (P > 0.05).

CONCLUSIONS

Access to the "Shared Decision Making Assistant" enhanced the PLC patients' performance and improved their quality of decision making in the areas of decision conflict, decision preparation, decision self-efficacy, knowledge of PLC treatment and satisfaction. Therefore, we recommend promoting and updating the "Shared Decision Making Assistant" in clinical employment and future studies.

Collaboration and Shared Decision-Making Between Patients and Clinicians in Preventive Health Care Decisions and US Preventive Services Task Force Recommendations

The US Preventive Services Task Force (USPSTF) works to improve the health of people nationwide by making evidence-based recommendations for preventive services. Patient-centered care is a core value in US health care. Shared decision-making (SDM), in which patients and clinicians make health decisions together, ensures patients' rights to be informed and involved in preventive care decisions and that these decisions are patient-centered. SDM has a role across the spectrum of USPSTF recommendations. For A or B recommendations (judged by the USPSTF to have high or moderate certainty of a moderate or substantial net benefit at the population level), SDM allows individual patients to decide whether to accept such services based on their personal values and preferences. For C recommendations (indicating at least moderate certainty of a small net benefit at the population level), SDM is critical for individual patients to decide whether the net benefit for them is worthwhile. For D recommendations (reflecting at least moderate certainty of a zero or negative net benefit) or I statements (low certainty of net benefit), clinicians should be prepared to discuss these services if patients ask. More evidence is needed to determine if, in addition to promoting patient-centeredness, SDM reduces inequities in preventive care, as well as to define new strategies to find time for discussion of preventive services in primary care.

Patient engagement strategies for adults with chronic conditions: an evidence map

BACKGROUND

Patient and family engagement (PFE) has been defined as a partnership between patients, families, and health care providers to achieve positive health care outcomes. There is evidence that PFE is critical to improving outcomes. We sought to systematically identify and map the evidence on PFE strategies for adults with chronic conditions and identify areas needing more research.

METHODS

We searched PubMed, CINAHL, EMBASE, and Cochrane, January 2015 to September 2021 for systematic reviews on strategies for engaging patients with chronic conditions and their caregivers. From each review, we abstracted search dates, number and type of studies, populations, interventions, and outcomes. PFE strategies were categorized into direct patient care, health system, and community-policy level strategies. We found few systematic reviews on strategies at the health system, and none at the community-policy level. In view of this, we also searched for original studies that focused on PFE strategies at those two levels and reviewed the PFE strategies used and study findings.

RESULTS

We found 131 reviews of direct patient care strategies, 5 reviews of health system strategies, and no reviews of community-policy strategies. Four original studies addressed PFE at the health system or community-policy levels. Most direct patient care reviews focused on self-management support (SMS) (n = 85) and shared decision-making (SDM) (n = 43). Forty-nine reviews reported positive effects, 35 reported potential benefits, 37 reported unclear benefits, and 4 reported no benefits. Health system level strategies mainly involved patients and caregivers serving on advisory councils. PFE strategies with the strongest evidence focused on SMS particularly for patients with diabetes. Many SDM reviews reported potential benefits especially for patients with cancer.

DISCUSSION

Much more evidence exists on the effects of direct patient care strategies on PFE than on the effects of health system or community-policy strategies. Most reviews indicated that direct patient care strategies had positive effects or potential benefits. A limitation of this evidence map is that due to its focus on reviews, which were plentiful, it did not capture details of individual interventions. Nevertheless, this evidence map should help to focus attention on gaps that require more research in efforts to improve PFE.